Confronting Insomnia

Kelly, 43, describes a problem that is all too common among women: “I have every type of sleep deprivation there is, from not being able to fall asleep to falling asleep and then waking up every two hours. I just don’t sleep.”

What Is Insomnia?

Insomnia affects millions of people in the United States. The condition involves trouble falling asleep, trouble staying sleep, and waking up early and being unable to go back to sleep.1Chronic insomnia—often defined as insomnia that lasts for at least a month—can cause concentration and memory problems, difficulty functioning at work and school, irritability and other mood problems, headaches, gastrointestinal symptoms, and worry about sleep. The causes of insomnia are not well understood, but the condition tends to become common as people age, and it is also more common in women, particularly after menopause.

For Kelly the problem began in her thirties: “I was diagnosed with perimenopause at 35. I started having signs like bed sweats and hot flashes. Everything else has been treatable, through hormone creams and different things that I do and eat, but for the sleeping, nothing worked.”

Treatment

Good sleep hygiene can help us all get a better night’s sleep (see sidebar “Sleep Hygiene: Tips from the Centers for Disease Control and Prevention”) and may be sufficient to relieve occasional sleep problems. People with chronic insomnia that affects their daily life, however, may benefit from seeking medical treatment. Many people attempt to manage their sleep problems on their own, but the approaches that have clear evidence to support their effectiveness are cognitive-behavioral treatments and prescription sleep medications.2 Behavioral approaches appear to be at least as effective as prescription medications and may be more useful than medications for long-term management of insomnia. Prescription medications can, however, provide important relief for some patients. If an underlying medical problem is contributing to the insomnia, it is also important to manage that condition.

Prescription Sleep Medications
Many different prescription sleep medications are available, with some meant primarily for short-term use and others approved for longer-term use. The choice of which drug to use depends in part on the symptoms that you are experiencing. Some drugs are better than others at helping you fall asleep quickly, and other drugs may help you sleep longer or fall back asleep after a middle-of-the-night awakening. Drugs known as benzodiazepine receptor agonists are commonly used for the treatment of insomnia, and include Sonata® (zaleplon), Lunesta® (eszopiclone), Ambien®, Edluar®, Intermezzo®, and Zolpimist® (zolpidem), as well as several related drugs.2 Two drugs with other mechanisms are Rozerem® (ramelteon), which acts on the melatonin pathway in the brain, and Silenor® (doxepin), which blocks histamine. The different types of drugs act on different receptors in the brain that affect sleep and wakefulness.

Although prescription sleep drugs can provide benefits, they also have the potential for some notable side effects. In 2007, for example, the US Food and Drug Administration (FDA) required manufacturers to include stronger language on the drug label about risks such as “complex sleep-related behaviors.”3 These behaviors occur at night when the person is not fully awake and can include eating, having sex, making phone calls, and even driving. The next day the person typically has no memories of these activities.

More recently, in January 2013, the FDA recommended a reduction in the dose of certain zolpidem-containing medications (Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist, and some generics).4 For some patients—particularly women—the drug stayed in the body long enough to interfere with alertness the next morning, even when the patient felt completely awake. A major concern was that this could contribute to impaired driving and traffic accidents. The FDA also reminded the public that all insomnia drugs—including over-the-counter sleep medications—may cause some loss of alertness the next day.

A common concern among patients is that use of sleep medications may lead to physical dependence on the drug, and this can occur with the benzodiazepine receptor agonists.5,6 Longer-term use may increase the likelihood of dependence, and risk also appears to be higher among people with a history of alcohol or drug abuse. Silenor and Rozerem are not benzodiazepine receptor agonists and do not appear to cause physical dependence.

Kelly started using Lunesta about five years go. “Sleeping is worse when I travel, and it started getting to the point where I would go for three or four days without any sleep. So I started using Lunesta when I was traveling, and it works great. I also use it at home if I need to.” She currently takes it less than once a month and hasn’t noticed any side effects. Asked about the rest of the nights that she has sleep problems, she responds, “I’ve just gotten used to it. More than anything, I’ve just gotten used to it.” Kelly makes a point of staying physically active and notices that she wakes up less at night after being highly active during the day. Avoidance of alcohol also helps: “If I drink anything at all, I will be up all night,” she says.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy gets to the root of insomnia through several strategies: correcting misperceptions about sleep, addressing negative thoughts about sleep, learning relaxation techniques and ways to control stimuli, and changing sleep behavior. People may be told to restrict the amount of time they spend in bed, for example, or to get out of bed for a short period of time if they find that they are not falling asleep. The idea is that learned thoughts and behaviors perpetuate insomnia but can also be used to treat the condition.2

Although no single approach will work for everyone, the evidence supporting the effectiveness of cognitive-behavioral therapy is strong. Studies suggest that cognitive-behavioral therapy is at least as effective as sleep medications,7 and it can be used long-term to manage sleep problems. Cognitive-behavioral therapy can be used alone or in combination with sleep medication and may reduce the need for medications.8

Over-the-Counter Sleep Aids

Although many products are sold over-the-counter as sleep aids, information about their efficacy is limited. These products often contain an antihistamine such as diphenhy-
dramine, either alone or in combination with a pain reliever. Side effects of antihistamine drugs include daytime grogginess, dry mouth, blurred visions, urinary retention, and constipation.9 Furthermore, tolerance to the sedating effects of these drugs appears to develop quickly.10 Melatonin and valerian are also marketed as sleep aids, but their effects on sleep appear to be modest at best.11,12

If you are considering an herbal product or other dietary supplement to help with sleep, be aware that “natural” does not necessarily mean safe; these products can have risks and may interact with other medications. Kava, for example, has a history of being used to treat insomnia but can cause severe liver damage.13

Conclusions

Insomnia is a common problem in women, particularly as we age. Prescription sleep medications and cognitive-behavioral strategies have both been shown to be effective. As summarized in a 2013 article on insomnia published in the Journal of the American Medical Association, “Behavioral treatments should be used whenever possible, and medications should be limited to the lowest necessary dose and shortest necessary duration.”2

Research into the causes, course, and long-term management of insomnia has been identified as a priority by the National Institutes of Health. If you are interested in participating in a clinical trial of new approaches to insomnia management, talk with your doctor. Information about ongoing clinical trials is also available at clinicaltrials.gov. _

16. Sleep and Sleep Disorders. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/features/sleep. Accessed June 26, 2013.

How Does Exercise
Affect Sleep?

Here is another reason to go for a walk or hit the gym: for reasons that are still not well understood, physical activity improves sleep. In a small study of older adults with chronic insomnia, for example, aerobic physical activity improved several measures of sleep and also improved daytime function.14 And in a study of postmenopausal women, sleep improved as level of physical activity increased, but even low levels of physical activity reduced the likelihood of a significant sleep disturbance.15 Some people believe that exercising shortly before bedtime interferes with sleep, but research on this question has been limited and inconsistent. Find what works for you.

Sleep Hygiene: Tips from the Centers for Disease Control and Prevention

Go to bed at the same time each night and rise at the same time each morning.

Sleep in a quiet, dark, and relaxing environment that is neither too hot nor too cold.

Make your bed comfortable and use it only for sleeping and not for other activities, such as reading, watching TV, or listening to music.

Remove all TVs, computers, and other electronics from the bedroom.

Avoid large meals before bedtime.

Caffeine, tobacco, alcohol, and certain types of medications also interfere with sleep. If you have questions about how your medications affect sleep, talk with your doctor.16